Chapter 2

RELATED REVIEW OF LITERATURE

Level of Internet Addiction in Adolescent

According to Pallanti et al. (2006), Internet addiction can be found at any age and

in any social condition, but most of the research major attention has been focuses on

adolescent because adolescent seem to be a critical period of addiction vulnerability. The

research of Van Rooij and Van den Eijinden (2007) had reported that, using internet has

become one of the most popular leisure-time activities among adolescent in Western

societies. Adolescents in Netherlands of ages between 11 to 15 use the internet for leisure

activities and for adolescents aged 14 and older regard internet usage as an important

leisure-time acitivity than watching TV (Van den Eijiden et al., 2009). According to Lin and

Wu (2009). Older adolescents appear to be more dependent on the internet than younger

adolescent. Recent studies have found that 19.8% of adolescent in the world have

internet addiction and furthermore, it is associated with hostility (Huang et al., 2009). The

first widely “wired” generation now a day are preteens and teens and according to

eMarketer (2004). The number of preteens and teens online in US. Grew streadily from

26.6 million in 2000 to 34.3 million in 2003 and nearly one half of all youngsters were

online (Lin & Yu, 2008). However a recent survey from Forrester Research (2005) had

revealed that consumer between the age of 12 and 17 in North America were often online

daily and average almost 11 hours per week. On the other hand, a surver by Taiwan

Network Information Center (2008), should that the internet population in Taiwan has

reached 15 million. Among them, internet user of age under 20 accounted for about 2.86
million. Furthermore, the two groups with the highest rates of internet usage were 12 to

15 years old which is 98% and 16 to 20 years old that is 95.6% (Lin & Yu, 2008).

Based on Pallanti et al., (2006) research, 5.4% of the sample included 275 students with

the average of 16.67 ± 1.85 years and consisted of 52.4% males and 47.6% females.

This research also shown that in Italy, internet usage had a slower diffusion than in other

countries. However, in another research from China Internet Network Information Center

(2006) had shown that 123 million people had gone online, of which 14.9% were

teenagers below 18 years old and it has concluded that internet addiction is currently

becoming a serious mental health problem among Chinese adolescents. Chou and Hsiao

reported that the incidence rate of Internet addiction among Taiwan college students was

5.9%. Wu and Zhu indentified 10.6% of Chinese college students as addicted to Internet

(as cited in Gao et al. 2007). Based on Chen et al. (2005), the majority of online gaming

crime in Taiwan is theft (73.7%) and fraud (20.2%) and their research found that the age

of offenders is low with 3.3% between ages 15 to 20 years of age, 8.3% under 15 years

old (Wan & Chiou, 2007)

According to Park et al. (2008), there are more adolescent using the internet than

any other age group in South Korea. Based on their research 97.3% of South Korean

adolescents between the age of 6 and 19 years used the internet in 2005. Moreover, a

study has investigated the prevalence of internet addiction among South Korean

adolescents been made. In this study 903 adolescents participated and 10.7% of them

scored high on the Internet Addiction Scale and these youths were considered at high

risk for internet addiction. This phenomenon occurs because South Korea is an internet-
based society that provides numerous middle and high school adolescents with easy

internet access and Internet addiction among South Korean is serious.

Gender Difference in Internet Addiction

One the studies of Hamade (n.d.) showed the distribution of students among three

levels of internet addiction. It showed that 75.6% of female no sign of addiction compared

to only 46.6% of males. Besides that, less than 25% of females are addicted to the internet

and more compared to only 46.6% of males. Besides that, less than 25% of females are

addicted to the internet and more than 50% of male students are addicted. Moreover,

about 18% of males are highly addicted to the internet but females only 6% are highly

addicted. In other words, male students are more addicted to the internet than female

students such as spend time outside the house and with friends, and visit internet cafes,

game networks and other places. This freedom will make the more time surfing the

internet and consequently become more vulnerable to internet addiction. Lee et al. (2002)

stated that numerous studies have shown gender difference in the use of digital media

and the type of service girls and boys prefer are different. Besides thatm based on

(Subrahmanyam et al. (2001); Bickham et al., (2003), in early teens, girls use the

computer longer than boys, but for the late-teens this trends is reversed (Park 2009).

Gender differences in internet addiction can be explained by the types of content that

interest men and women. Interactive online games characterized by powerm dominance,

control, and violence attract more men than women. As an example, Young (1998)

observed that men tend to seek out dominant activities. Women, on the other hand, seek

out close friendships and prefer anonymous communication in which they can hide their

identity. Van Schie & Wiegman (1997) have another study which showed that boys enjoy
online games more than girls. This preference makes boys heavy users of the internet

(Park 2009). However, according to Azim, Zam, & Rahman (n.d.) stated that, gender

differences and trends in age groups are often observed in many study. One of the studies

by Young (1996) showed that middle-aged women were more prone to internet addiction

than men and other age groups. While on Davis et al. (1999) have compared gender

differences in internet use. They found that male students spend more time online than

female in the public university. However, in private university there was no significant

gender differences in tern of the time spent online (Rahman etal., n.d.). One of the studies

by Barroes et al., (2001) showed that, male students were more internet dependent than

women. Dependents were for times more likely than non-dependents to report academic

impairment die to their internet use (Rahman et al., n.d.).

Park et al., (2009) concluded that: However, previous studies reported that 4.6% of girls

and 4.7% of boys among 12-18 years old Finnish youth (Lintonen et al., 2004) and total

of 1.98% (2.42% for boys and 1.51% for girls) among Norwegain youth (12-18 years) met

criteria of internet addiction (Johansson & Gotestam, 2004)

According to Hunley et al. (2005) had a report about the amount of time spent on

the computer was similar across gender. Tsai and Lin (2004) study, found that there was

no significant gender difference in adolescents’ Internet self-efficacy, and they suggesting

that both genders were competently mastering it. In another word, both genders appear

now to have equivalent resources and experience in accessing the internet. Although

based on this study, gender differences in computer use are narrow but there is gender

gap in online activities and in the content that is accessed (Lin & Yu, 2008). Mediamark

Research (2005) had reported that, boys (28.9%) were more likely to play games than
were girls (11.1%). Besides that, Griffiths et al. (2004) also support that boy tended to

play games more often than did girls (Lin & Yu 2008). Tsai and Lin (2004) had also stated

that, males tended to consider the internet more as a “toy”, but females tended to view it

as a tool or as technology with which accomplish task (Lin & Yu, 2008). As previously

stated, researchers have found that male and female use internet differently, and

according to The Pew Internet and American Life (2005), man are more likely than women

to use the internet more for information gathering while women more to use in

communication (McMahan, 2005).

The study of Rees and Noyes (2007) found that there is significant gender

difference that were reported for computer and internet use, internet attitudes, and

computer anxiety. Although males and female were generally used these technologies,

but females are less frequent user of technology as compared to males and that females

have less positive attitude and greater anxiety toward technology (Rahmanm n.d.).

However, a study by Ferraro et al. (2007) used Italian version of Young’s Internet

Addiction Test (IAT). Result revealed that no significant differences were found between

male and female (Rahman, n.d.).

According to Hiroshi and Zavodny (2005) internet use in different location or

countries have different result in gender differences. In the US. Internet use at various

locations increased over time among woman relative to men. In 1996 and 1998 were less

likely to use internet anywhere or at home but they were more likely to do so by 2001.

Nevertheless, woman in Japan are much less likely to use internet than men regardless

of location, and this difference has not narrowed significant over time. In general, this

research had found that gender inequality in labor markets and human capital
development carries over to gender difference in IT use. In contrasting patterns of IT

access and use in US and Japan reflected differences in the structure of social

organization and labor market institution in two cultures. A study was examined the

internet addiction between male undergraduate Human Sciences students of Internation

Islam University Malaysia (IIUM). This study showed that there were no significant

differences in internet addiction between male and female in Human Sciences students

(Rahman et al. n.d.).

Effects of Internet Addiction

According to (http://www.thewisdompost.com/essay/internet-addiction/) People

who spend hours on the internet start to see some negative effects in their lives. In a

survey, it was found that internet addicts spend more than 60% of their time online.

Addiction comes out as a compulsive need to engage in an activity that poses threat to

other areas of life. The idea of internet addiction seems to be silly, especially in those who

do not have any kind of disorder. Addictive behavior can be defined as something that

increases tolerance levels or the need to spend more time. People who spend unusual

amount of time online meet all the key criteria for addiction. The effects of internet

addiction tend to become apparent with time. Also, Relationship Issues is the most

common effect of internet addiction. When someone is immersed in online activities for a

longer period, it means they are not interested in real world activities. The changes

become more apparent in terms of friends, family and beloved ones. Certain types of

internet addiction such as online casino, gambling, rummy etc. poses certain threats to

stability in relationship. Similarly, continuous web surfing can cause threat to close

relationships. Loss of relationship in person’s life results in loss of self-identity and

connection with life. In addition to that depression could be one of the possible causes of

internet addiction. Depressed people may use internet as a self-medication to feel better,

as it allows them to ignore the problems they are facing currently. Remember that they

feel better for a time being only. Internet addiction can worsen the symptoms of

depression when they logout. They still have to face their problems and deal with them,

rather than putting them off.

Besides the above effects, internet addicts may notice decreased levels of personal

hygiene. They hardly care about their looks. Internet addicts tend to feel zoned out after

several hours of internet usage. Moreover, they may develop physical symptoms such as

– back, shoulder, joints and hand pain. Some people even develop poor eyesight issues

due to prolonged hours in front of computer.

Etiology

There are different models available for the development and maintenance of IAD

like the cognitive-behavioral model of problematic Internet use (Davis RA, 2001), the

anonymity, convenience and escape (ACE) model ( Young KS et al.,200) the access,

affordability, anonymity (Triple-A) engine (Cooper A et al,1999) a phases model of

pathological Internet use by Grohol (1999), and a comprehensive model of the

development and maintenance of Internet addiction by Winkler & Dörsing (2011), which

takes into account socio-cultural factors (e.g., demographic factors, access to and

acceptance of the Internet), biological vulnerabilities (e.g., genetic factors, abnormalities

in neurochemical processes), psychological predispositions (e.g., personality

characteristics, negative affects), and specific attributes of the Internet to explain

“excessive engagement in Internet activities” ( Winkler et al. 2011).

Neurobiological Vulnerabilities

It is known that addictions activate a combination of sites in the brain associated

with pleasure, known together as the “reward center” or “pleasure pathway” of the brain

(Linden DJ, 2011). When activated, dopamine release is increased, along with opiates

and other neurochemicals. Over time, the associated receptors may be affected,

producing tolerance or the need for increasing stimulation of the reward center to produce

a “high” and the subsequent characteristic behavior patterns needed to avoid withdrawal.

Internet use may also lead specifically to dopamine release in the nucleus accumbens

(Bai Y-M et al. 2001), one of the reward structures of the brain specifically involved in

other addictions (www.asam.org/1DEFINITION_OF_ ADDICTION_LONG)

An example of the rewarding nature of digital technology use may be captured in the

following statement by a 21-year-old male in treatment for IAD:

“I feel technology has brought so much joy into my life. No other activity relaxes me or

stimulates me like technology. However, when depression hits, I tend to use technology

as a way of retreating and isolating.”

Biological Predisposition

There is increasing evidence that there can be a genetic predisposition to addictive

behaviors (Eisen S. et al.1998). The theory is that individuals with this predisposition do

not have an adequate number of dopamine receptors or have an insufficient amount of

serotonin/dopamine (Beard KW, 2005) thereby having difficulty experiencing normal

levels of pleasure in activities that most people would find rewarding. To increase

pleasure, these individuals are more likely to seek greater than average engagement in

behaviors that stimulate an increase in dopamine, effectively giving them more reward

but placing them at higher risk for addiction.

Mental Health Vulnerabilities

Many researchers and clinicians have noted that a variety of mental disorders co-

occur with IAD. There is debate about which came first, the addiction or the co-occurring

disorder (Kratzer S. 2008) The study by Dong et al. (2011) had at least the potential to

clarify this question, reporting that higher scores for depression, anxiety, hostility,

interpersonal sensitivity, and psychoticism were consequences of IAD. But due to the

limitations of the study further research is necessary.

Psychological Approaches

Motivational interviewing (MI) is a client-centered yet directive method for

enhancing intrinsic motivation to change by exploring and resolving client ambivalence

(Miller WR. et al., 2002) It was developed to help individuals give up addictive behaviors

and learn new behavioral skills, using techniques such as open-ended questions,

reflective listening, affirmation, and summarization to help individuals express their

concerns about change ( Miller NH., 2010) Unfortunately, there are currently no studies

addressing the efficacy of MI in treating IAD, but MI seems to be moderately effective in

the areas of alcohol, drug addiction, and diet/exercise problems ( Burke BL. 2003)

Peukert et al. (2010) suggest that interventions with family members or other relatives

like “Community Reinforcement and Family Training” (Meyers RJ. 2001) could be useful
in enhancing the motivation of an addict to cut back on Internet use, although the

reviewers remark that control studies with relatives do not exist to date.

Reality therapy (RT) is supposed to encourage individuals to choose to improve their lives

by committing to change their behavior. It includes sessions to show clients that addiction

is a choice and to give them training in time management; it also introduces alternative

activities to the problematic behavior (. Kim J-U. 2007). According to Kim (2007), RT is a

core addiction recovery tool that offers a wide variety of uses as a treatment for addictive

disorders such as drugs, sex, food, and works as well for the Internet. In his RT group

counseling program treatment study, Kim found that the treatment program effectively

reduced addiction level and improved self-esteem of 25 Internet-addicted university

students in Korea (Kim J-U. 2008). Twohig and Crosby used an Acceptance &

Commitment Therapy (ACT) protocol including several exercises adjusted to better fit the

issues with which the sample struggles to treat six adult males suffering from problematic

Internet pornography viewing (Twohig et al., 2010). Widyanto and Griffith report that most

of the treatments employed so far had utilized a cognitive-behavioral approach (Widyanto

et al. 2006) The case for using cognitive-behavioral therapy (CBT) is justified due to the

good results in the treatment of other behavioral addictions/impulse-control disorders,

such as pathological gambling, compulsive shopping, bulimia nervosa, and binge eating-

disorders (Abreu CN. 2011) Wölfling (2009) described a predominantly behavioral group

treatment including identification of sustaining conditions, establishing of intrinsic

motivation to reduce the amount of time being online, learning alternative behaviors,

engagement in new social real-life contacts, psycho-education and exposure therapy, but

unfortunately clinical evidence for the efficacy of these strategies is not mentioned. In her
study, Young (2007) used CBT to treat 114 clients suffering from IAD and found that

participants were better able to manage their presenting problems post-treatment,

showing improved motivation to stop abusing the Internet, improved ability to control their

computer use, improved ability to function in offline relationships, improved ability to

abstain from sexually explicit online material, improved ability to engage in offline

activities, and improved ability to achieve sobriety from problematic applications. Cao, Su

and Gao (2007) investigated the effect of group CBT on 29 middle school students with

IAD and found that IAD scores of the experimental group were lower than of the control

group after treatment. The authors also reported improvement in psychological function.

Thirty-eight adolescents with IAD were treated with CBT designed particularly for addicted

adolescents by Li and Dai (2009). They found that CBT has good effects on the

adolescents with IAD (CIAS scores in the therapy group were significantly lower than that

in the control group). In the experimental group the scores of depression, anxiety,

compulsiveness, self-blame, illusion, and retreat were significantly decreased after

treatment. Zhu, Jin, and Zhong (2009) compared CBT and electro acupuncture (EA) plus

CBT assigning forty-seven patients with IAD to one of the two groups respectively. The

authors found that CBT alone or combined with EA can significantly reduce the score of

IAD and anxiety on a self-rating scale and improve self-conscious health status in patients

with IAD, but the effect obtained by the combined therapy was better.

Multimodal Treatments

A multimodal treatment approach is characterized by the implementation of several

different types of treatment in some cases even from different disciplines such as

pharmacology, psychotherapy and family counseling simultaneously or sequentially.

Orzack (1999) mentioned that treatments for IAD need to be multidisciplinary including

CBT, psychotropic medication, family therapy, and case managers, because of the

complexity of these patients’ problems.

In their treatment study, Du, Jiang, and Vance (2010) found that multimodal school-based

group CBT (including parent training, teacher education, and group CBT) was effective

for adolescents with IAD (n = 23), particularly in improving emotional state and regulation

ability, behavioral and self-management style. The effect of another multimodal

intervention consisting of solution-focused brief therapy (SFBT), family therapy, and CT

was investigated among 52 adolescents with IAD in China. After three months of

treatment, the scores on an IAD scale (IAD-DQ), the scores on the SCL-90, and the

amount of time spent online decreased significantly (Fang-ru Y & Wei H. 2005). Orzack et

al. (2006) used a psychoeducational program, which combines psychodynamic and

cognitive-behavioral theoretical perspectives, using a combination of Readiness to

Change (RtC), CBT and MI interventions to treat a group of 35 men involved in

problematic Internet-enabled sexual behavior (IESB). In this group treatment, the quality

of life increased and the level of depressive symptoms decreased after 16 (weekly)

treatment sessions, but the level of problematic Internet use failed to decrease

significantly (Orzack MH, 2005). Internet addiction related symptom scores significantly

decreased after a group of 23 middle school students with IAD were treated with

Behavioral Therapy (BT) or CT, detoxification treatment, psychosocial rehabilitation,

personality modeling and parent training (Rong Y. et al., 2006) Therefore, the authors

concluded that psychotherapy, in particular CT and BT were effective in treating middle

school students with IAD. Shek, Tang, and Lo (2009) described a multi-level counseling
program designed for young people with IAD based on the responses of 59 clients.

Findings of this study suggest this multi-level counseling program (including counseling,

MI, family perspective, case work and group work) is promising to help young people with

IAD. Internet addiction symptom scores significantly decreased, but the program failed to

increase psychological well-being significantly. A six-week group counseling program

(including CBT, social competence training, training of self-control strategies and training

of communication skills) was shown to be effective on 24 Internet-addicted college

students in China (Bai Y. 2007). The authors reported that the adapted CIAS-R scores of

the experimental group were significantly lower than those of the control group post-

treatment.

The Restart Program

The authors of this article are currently, or have been, affiliated with the reSTART:

Internet Addiction Recovery Program (www.netaddictionrecovery.com .) in Fall City,

Washington. The reSTART program is an inpatient Internet addiction recovery program

which integrates technology detoxification (no technology for 45 to 90 days), drug and

alcohol treatment, 12 step work, cognitive behavioral therapy (CBT), experiential

adventure based therapy, Acceptance and Commitment therapy (ACT), brain enhancing

interventions, animal assisted therapy, motivational interviewing (MI), mindfulness based

relapse prevention (MBRP), Mindfulness based stress reduction (MBSR), interpersonal

group psychotherapy, individual psychotherapy, individualized treatments for co-

occurring disorders, psycho- educational groups (life visioning, addiction education,

communication and assertiveness training, social skills, life skills, Life balance plan),
aftercare treatments (monitoring of technology use, ongoing psychotherapy and group

work), and continuing care (outpatient treatment) in an individualized, holistic approach.

The first results from an ongoing OQ45.2 (Lambert MJ. Et al., 20014) study (a self-

reported measurement of subjective discomfort, interpersonal relationships and social

role performance assessed on a weekly basis) of the short-term impact on 19 adults who

complete the 45+ days program showed an improved score after treatment. Seventy-four

percent of participants showed significant clinical improvement, 21% of participants

showed no reliable change, and 5% deteriorated. The results have to be regarded as

preliminary due to the small study sample, the self-report measurement and the lack of a

control group. Despite these limitations, there is evidence that the program is responsible

for most of the improvements demonstrated.

Prevention of Internet Addiction

When it comes to technology, you should create a healthy work-life balance. There

are some simple ways to prevent internet addiction and live a healthy life. To seek help

with internet addiction disorder, you should be given a mental test to assess your

dependency on the internet. The most common assessment to make diagnosis of internet

addiction include – problematic internet use questionnaire, compulsive internet use scale

and internet addiction test. Many of us surf the internet and there is a fine line between

casual surfing and compulsive surfing. If you fear that you may lose interest in real life

activities as you prefer to be on the internet, you may be on your way to addiction.

However, to prevent internet addiction, set aside some time for computer use. If you have

a laptop, do not use it on holidays. Keep it somewhere and try not to go near it. Keep the

screen closed, if you are not using it. When the computer is no looking at you, you are
less likely to use it. Use an alarm clock as time to limit computer usage time. You can

even program your computer in such a way that it shuts down automatically after 30-40

minutes or you can go for a short trip with your family or even friends. Instead of watching

TV or getting involved in individual things – you should spend some time with your family.

You can even watch a movie along with your family or go out for an evening walk.

(www.thewisdompost.com/essay/internet-addiction).